HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 OLYMPIC LANE 6/14/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SUN 14 7021
Form 4 TOWN OF NORTH ANDOVER
r••• HEALTH DEPARWENT
DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio e /Righ onf of housd, Left/Right rear of house, Left/right side of house, Left
Right side of bu ' g, Left/Right ron of building, Left/Right rear of building, Under deck
Address Cc-� l
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Zip a�
Telephone Number
B. Pumping Record
1. Date of Pumping pat 2. Quantity Pumped: 6�lons
3. Type of system: ❑ Cesspool(s) 0-8eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U_Nv If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents,were disposed:
G L S Lowell Waste Water
4MOA. r
Signitule qt Haule4 Date
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